Rita Taylor

“The failure to appropriately manage Mrs [name redacted] hyponatraemia by the on call consultant physician on the 31st July 2017 on the grounds that it was not his sphere of expertise. No contact was considered or made to someone who may have been able to assist leaving Mrs [name redacted] to languish overnight with no management plan in place and a lack of any meaningful documentation in her hospital notes.”

“The failure, at any time between the 31st July 2017 and 5th August 2017 to follow the national recommended guidelines for the management and treatment of hyponatraemia, in particular the need to measure serum sodium regularly and to limit the rate of rise of serum sodium to prevent complications.”

“The failure, at any time between the 31st July 2017 until the 6th August 2017 to create a coherent plan for the management of Mrs [name redacted] medical problems resulting in the failure to assess fluid balance or to reintroduce desmopressin, given a known diagnosis of diabetes insipidus on a background of a pituitary adenoma.”

“The apparent lack of understanding of the appropriate management of hyponatraemia by consultants whose care Mrs [name redacted] was under, despite two emergency consultant physicians having a specialist interest in endocrinology. Whilst some attempt was made to contact St George's hospital this was not successfully followed through to assist them in their management.”

“The failure of an emergency consultant physician with an interest in endocrinology to understand that giving intravenous fluids with potassium is not an appropriate method to increase serum potassium levels, more so as Mrs [name redacted] at that time could eat and drink normally.”

“The documentation throughout Mrs [name redacted] admission until transfer to the high dependency unit was inadequate with no record of assessment or a coherent management plan in place to ensure appropriate care and continuity of that care for succeeding physicians to consider or to follow.”